PHYSICAL ACTIVITY READINESS

QUESTIONNAIRE
PATIENT’S NAME: ________________________________________ DOB: _____________________ DATE: _____________________

HEALTH CARE PROVIDER’S NAME: _______________________________________

Please read the questions below carefully, and answer each one honestly. Please check YES or NO.

 Yes  No Has your health care provider ever said that you have a heart condition and that you should
only do physical activity recommended by a health care provider?
 Yes  No Do you feel pain in your chest when you do physical activity?
 Yes  No In the past month, have you had chest pain when you were not doing physical activity?
 Yes  No Do you lose your balance because of dizziness or do you ever lose consciousness?
 Yes  No Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse
by a change in your physical activity?
 Yes  No Is your health care provider currently prescribing drugs (for example, water pills) for your blood
pressure or heart condition?
 Yes  No Do you know of any other reason why you should not do physical activity?

Excerpted from the Physical Activity Readiness Questionnaire (PAR-Q) © 2002. Used with permission from the Canadian
Society for Exercise Physiology.

PHYSICAL ACTIVITY READINESS

QUESTIONNAIRE
PATIENT’S NAME: ________________________________________ DOB: _____________________ DATE: _____________________

HEALTH CARE PROVIDER’S NAME: _______________________________________

Please read the questions below carefully, and answer each one honestly. Please check YES or NO.

 Yes  No Has your health care provider ever said that you have a heart condition and that you should
only do physical activity recommended by a health care provider?
 Yes  No Do you feel pain in your chest when you do physical activity?
 Yes  No In the past month, have you had chest pain when you were not doing physical activity?
 Yes  No Do you lose your balance because of dizziness or do you ever lose consciousness?
 Yes  No Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse
by a change in your physical activity?
 Yes  No Is your health care provider currently prescribing drugs (for example, water pills) for your blood
pressure or heart condition?
 Yes  No Do you know of any other reason why you should not do physical activity?

Excerpted from the Physical Activity Readiness Questionnaire (PAR-Q) © 2002. Used with permission from the Canadian
Society for Exercise Physiology.